Terms Related to Processing Medical Bills
The following are some terms that are related to processing medical bills:
Beneficiary: In relation to processing medical bills, a beneficiary is someone who is covered by a health insurance policy.
Capitation: Capitation is how much policyholders or their employers are required to pay a health insurance agency. This amount is not based on how often the policy is actually used.
Coinsurance: Coinsurance, often referred to as co-payment, is how much a person needs to pay toward medical bills before the health insurance agency will help cover expenses. Coinsurance is commonly represented by a certain percentage. In some cases there is a flat fee required whenever a beneficiary visits a hospital or medical office, though this amount is usually small.
Exclusion: Exclusions are parts of health insurance policies that outline specific items that are not covered by the plan. This may include certain things like plastic surgery that is deemed medically unnecessary.
Guaranteed Issue: A guaranteed issue insurance policy is one that grants coverage to an individual without regard to their income, age, current health, and similar factors. A guaranteed issue policy will continue to remain in effect so long as the policyholders continue to pay for it.
Medical Underwriting: Medical underwriting refers to health insurance companies determining an individual’s eligibility, or ineligibility, for coverage. This is also how the cost of the policy is determined.
Primary Care Provider: A primary care provider, or PCP, is the main healthcare physician that an individual visits. PCPs are usually general practitioners, not specialists.
Reasonable and Customary Fees: Reasonable and customary fees are essentially the average cost for medical services in a certain location. The amount that an insurance policy will pay for office visits, hospital care, and other medical services will be based on this amount.
Rider: A rider is a change of an insurance policy that typically alters included benefits or payment amounts.
Stop-loss: Stop-loss occurs when the policyholder has covered all deductions, co-payments, and other fees and the insurance company is paying for the entirety of all claims that are included on the policy.